Southern Sun Hotel Rosebank, Johannesburg – Saturday 18 November 2023

Please complete the Registration Form below (all fields are compulsory) – please note: You will receive an invoice from the SASTM Office with payment details. Prices shown below include VAT.

SASTM Member Doctor: R 2 750. | SASTM Member Nurse/Allied: R 2 300.

Non-SASTM Member Doctor: R 3 000. | Non-SASTM Member Nurse/Allied: R 2 600.

There will be a surcharge of R 500. for Halaal and Kosher Meals added to registration if applicable and selected in the Registration Form

REGISTRATION IS CLOSED

Registration Form:

Company / Clinic Name:

Company / Clinic Physical Address:

Physical Address:

City:

Province:

Postal Code / Zip Code:

Country / Region:

***

Phone Number – Work:

Cellphone Number:

VAT Number:

Practice Number:

Personal Information:

Title:

First Name:

Last Name:

Gender:

ID Number:

Job Title:

Profession:

Personal Email Address:

Postal Address:

Postal Address:

Postal City:

Postal Province:

Postal Code:

Postal Country:

***

Medical Registration Board: HPCSA / SANC / Allied Health / Pharmacy Council / Other?:

Medical Registration Number:

Do you have any dietary requirements?: Halaal / Kosher / None? Please note there is a surcharge of R 500. incl. VAT for Halaal or Kosher meals:

Submit

Your form was submitted successfully!

Sorry! your form was not submitted properly, Please check the errors above.